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Table 2
32 , 33
Details of shingles vaccines
Vaccine Characteristics Dosage and cost Indications
Zostavax ( MSD )
Shingrix ( GSK )
Live attenuated virus
Single dose , 0.65ml £ 99.96
Recombinant Two doses of 0.5ml each , two months apart £ 160 per dose
Pain can be treated with paracetamol alone or in combination with codeine or a nonsteroidal antiinflammatory drug ( such as ibuprofen ). It is important that these are taken regularly . 15 Itching can be treated by antihistamines such as chlorpheniramine ( Piriton ).
Infection risks Vesicles contain the herpes varicella zoster virus and contact with vesicle liquid could potentially cause chickenpox infection in a person who has not had it earlier in life . The risk is very low since most people have immunity through childhood exposure to chickenpox .
A person with shingles should be advised to avoid contact with anyone who has not had chickenpox , particularly pregnant women and immunocompromised people , as well as babies who are less than a month old . Bedlinen , clothing and towels should be laundered separately until the rash has dried up . Weeping vesicles should be dressed to avoid contact with others .
Primary care staff should follow their local infectioncontrol policy and use protective equipment if there is a risk of contact with blood and body fluids .
Prevention of herpes zoster and postherpetic neuralgia in adults
Prevention of herpes zoster and postherpetic neuralgia in adults > 50 years Adults > 18 years of age at increased risk of herpes zoster
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Complications While people normally recover from shingles without any additional issues , there are a number of potentially serious complications ( Table 1 ). 18 The most common are PHN and secondary infection . A third of patients aged 80 and older develop PHN , as do a fifth of over-50s . 19 Pain is usually unilateral and can be shooting , stabbing or burning . Treatment is with topical or oral medication . 20
NICE recommends simple analgesia such as paracetamol , but codeine may be added if required . Medications to treat neuropathic pain include amitriptyline ( 10-20mg ) 21 and duloxetine . The anticonvulsants gabapentin and pregabalin can be used 22 but can cause drowsiness and increase risk of falls , especially in frail older people . 23 Capsaicin , the component of chilli peppers that causes burning , can be applied in cream form . 24 Skin patches with 5 or 8 per cent lidocaine can be applied to the painful area for around 12 hours in a 24-hour period . 25 The 5 per cent patch has fewer side-effects , is better tolerated and works faster . Secondary bacterial infection can occur , so good hygiene is important . Affected skin can be washed with clear water and patted dry gently . The person should wear soft , light clothing that is changed at least daily .
If skin becomes hot , itchy and uncomfortable topical therapy such as calamine lotion may help . Gauze soaked in Burow ’ s solution ( 5 per cent aluminium acetate ) can cool and soothe the skin and is also thought to have antibacterial properties that can cut the risk of infection .
If the rash is weeping , then non-adherent dressings should be used and changed as necessary . Antibiotic therapy may be required to treat any secondary infection .
Around 10 per cent of people with shingles develop ophthalmic complications 26 . A small number who develop eye or neurological complications may not have had a rash . 27 People who have neurological or eye symptoms are at risk of ophthalmic complications and should be referred for appropriate specialist advice .
Immunisation programme The NHS shingles vaccination programme began in 2013 . The number of people being vaccinated is rising , with around 44 % of 71-year-olds and 82 % of 79-year-olds now treated under the programme . 28 Vaccination is reported to have averted 40,500 GP consultations and 1,840 hospitalisations in England over a five-year period . ⁵
Two vaccines were initially introduced : Zostavax MSD , a live attenuated virus given to most eligible people , and Shingrix GSK ( a recombinant sub-unit vaccine ), given to the immunocompromised ( see Table 2 ).
From September , Shingrix is to be given routinely to all eligible people via two doses , two months apart . 29 The Shingrix vaccine is 97.2 % effective , a significant improvement on 51 % for Zostavax . 30 The plan is to immunise all over-60s across a 10-year period . The first phase this year will target those turning 70 and 65 , and anyone over 50 who is immunocompromised , in addition to those aged 70-80 . The changes mean almost a million people in England will fall into eligible cohorts by 2033 . 31
Preparing for vaccinations Primary care staff can identify those eligible and ensure they are aware they can get the vaccine , which can be given at the same time as flu vaccination . If more than one vaccine is given at the same appointment , they should preferably be in different arms .
Linda Nazarko is a nurse consultant in physical health care at West London NHS Trust